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Kitchen Table Politics: The Cost And Quality Of Health Care

Kitchen Table Politics is a podcast series about the issues that affect your home, family and wallet and how they intersect with politics and public policy. Each of our five episodes is tied to a different stage in life, from birth through retirement. (The series, hosted by yours truly, lives within the FiveThirtyEight elections podcast feed. If you already subscribe, you’ll get all the episodes.)

This week, we look at the cost and quality of health care. We’ll discuss the changing prices of insurance plans on the Affordable Care Act exchanges and why prescription drugs can cost so much. Plus, we’ll talk about what the presidential candidates are proposing to make health care better.

Joining me this week are FiveThirtyEight public health reporter Anna Maria Barry-Jester and Larry Levitt, a senior vice president at the Kaiser Family Foundation, a health care policy nonprofit organization. The Kaiser Family Foundation has been polling Americans to find out how they feel about the Affordable Care Act and tracking insurance price changes state by state.

Health care in this country saw a major shift with the Affordable Care Act, which was passed in 2010, and the 2012 Supreme Court decision upholding the law. According to figures from the Centers for Disease Control and Prevention, 9 percent of Americans lacked insurance in 2015, down 6 percentage points from 2011 and 2.4 points from 2014. Medical debt is also dropping.

But many Americans still face challenges finding affordable quality health care. The cost of insurance plans on the Obamacare exchanges is rising in many states, prescription drug costs remain high, and 28.6 million people still don’t have insurance. In this episode, we talk about some solutions to those challenges, including what might lower the cost of prescription drugs and whether medical providers should be paid based on results instead of per service. We also discuss how the presumptive Republican and Democratic nominees for president are approaching health care and the future of the Affordable Care Act.

Throughout this series, we’ll be collecting your stories and playing excerpts during each episode. Below, listen to a few phone calls we received.

  • Anonymous caller: “I feel so lucky, and I don’t know what other families do.”
  • Ken: “Thanks to Obamacare … [my mother] has health insurance for the first time in her life.”
  • Bob: “People like myself who’ve had a stable job for a long time … are completely oblivious to how big and heavy a burden this [is].”
  • Ted: “I decided … [to] come back to Canada where I’m covered by health insurance as a citizen.”

Next week, we’re discussing saving for retirement. Have you saved enough? What’s your strategy? How much are you relying on government programs, and how much are you saving for yourself? To tell us your story, call 646-820-0538.

Here are some highlights from our conversation on health care. The transcript has been lightly edited for clarity.

The candidates on reducing costs

Farai Chideya: I want to take a look at the presidential election. There’s a very stark difference between the two presumptive nominees. Donald Trump’s plan is to repeal the Affordable Care Act, allow insurance sales across state lines, require price transparency from doctors and hospitals, import pharmaceuticals to allow cheaper drugs in from other countries and then — hearkening back to the days when you could write off your credit card debt — allow individuals to write off the full cost of insurance premiums on their taxes as businesses do. But his plan could double the number of uninsured, according to some estimates.

Clinton is running, as she does in many ways, with the Obama legacy. So: keep the Affordable Care Act, fix some loopholes in the law that make it hard for people to get subsidies, increase the subsidies, promoting fee for results instead of fee for service … and then tackling drug prices by allowing imports — and that might be the one way in which she and Donald Trump are alike. What do you make of these candidate proposals?

Larry Levitt: This is the first presidential election since the Affordable Care Act went fully into effect. And still Republicans are calling for a repeal of the law, and Democrats are committed to keeping it. I think it would be very hard for a Republican in the White House to actually repeal the ACA. I mean, 20 million people have been covered. It’s the status quo, and disrupting the status quo in health care is really hard.

Anna Maria Barry-Jester: We have really, really high costs, and both candidates have ideas about how to lower those costs. Are there specific policies that you think there’s good evidence for? I’m curious what you think is working.

Levitt: Well, you know, there is this movement in health care to get away from paying service by service, and instead structuring the payments to doctors and hospitals so that they have incentives to deliver care more efficiently and of higher quality. And you know, it makes logical sense that that would make a difference. But, at least so far, the evidence has been pretty mixed. It’s really hard to move the health care system; it’s kind of like an ocean liner. And tweaking payments may make a difference, but it’s hard to find those effects.

If you look at other countries, the main way they control health care is through regulatory power. They control the prices of drugs, and they control how much doctors and hospitals get paid. That, I think, has been demonstrated to lead to lower health care costs, but it’s also politically very difficult to do.

Chideya: The Kaiser Family Foundation has been doing polling on how citizens see the law — what are you finding nationwide?

Levitt: You know, it’s still an incredibly controversial law, and the public is divided on it like they have been from the start. It’s mostly people viewing Obamacare through a partisan lens — Republicans tend to hate it; Democrats tend to like it. That’s remarkable. We’ve polled even people who actually have insurance through these new health insurance exchanges, and even their partisanship tends to drive whether people feel they’ve benefited or been made worse off by the law.

Perception and reality

Chideya: Why are health care costs high, and how do we bring them down? I know that’s a big question.

Levitt: Yeah, that’s a big, complicated question. First, you have to define what we mean by “health care costs.” I think to experts we tend to look at how much the country is spending on health care, which is trillions of dollars a year. But when people are looking at health care, they don’t really care what the nation is spending, they care what they’re spending. So for what people are spending out of pocket, rising deductibles have been a part of that. Deductibles have been going up much faster than people’s wages, which have largely been stagnant. What people are finding [is that what they] are paying for health care out of their own pockets has been increasing quite substantially.

When you look at what the country as a whole is spending, it’s actually been going up quite slowly. We’ve been in this period of historically low increases in health care costs. Some of that was the hangover from the Great Recession, but some is just improvements in the delivery of health care that have made it more efficient. You know, another way of looking at health care spending is how much we spend relative to other countries. By far we spend more than any other developed country in the world on health care. And the big reason is prices. We actually don’t use more health care than people in other countries, but we pay much higher prices for doctor’s visits, hospitals and prescription drugs.

Barry-Jester: And of course the other side of that is that we in the U.S. provide what most people refer to as sick care. So we’re taking care of people who are sick, whereas in other countries they have higher spending on things like prevention and public health, which in theory are lowering the demand for health care.

Kitchen Table Politics is produced and edited by Galen Druke, Simone Landon and Jody Avirgan. Tony Chow and Lucina Melesio helped with production. Subscribe to the FiveThirtyEight elections podcast in iTunes or by searching “fivethirtyeight” in your favorite podcast app.

Farai Chideya is a former senior writer for FiveThirtyEight.